Friday, March 17, 2006

Letter from Shane E. Macaulay, M.D. to Washington State Board of Pharmacy

March 10, 2006

Washington State Department of Health
Board of Pharmacy
CenterPoint Corporate Park
20435 72nd Avenue
Kent, WA 98032

Dear Members of the Board:

I am a physician in private practice in Washington State. I have followed with interest the issues surrounding the assault on the right of pharmacists to exercise conscience in dispensing medication, and would like to make some comments to the Board on the subject. Thank you for taking a few moments to read this letter.

The right of all health care workers, including pharmacists, to act in accord with their conscience is fundamental to sound policy, ethics and human justice. It is recognized by the American Pharmacists Association Code of Ethics (IV) and is firmly enshrined in Washington State law (RCW 9.02.150, RCW 48.43.065 (2)(a) ). Recognition of this right to conscience is essential for the protection of the integrity of the entire profession of pharmacy.

Fundamental to the attack on the right of conscience is a devaluation of the profession of pharmacy and a disrespect for the knowledge, training and professionalism of pharmacists. Those who would deny pharmacists the right to exercise conscience would reduce pharmacists to mere dispensing clerks. In my medical training, pharmacists were an integral part of the health care team. In hospitals they joined the physicians rounding on patients and made recommendations regarding medications that were almost uniformly followed by the physicians. Stripping pharmacists of their autonomy and ability to critically analyze medications will reduce their value to all patients and impoverish the medical profession, and can be expected to produce alarming increases in medication errors.

If pharmacists are truly integral and valuable members of the healthcare team, they should be accorded the same rights and protections granted to physicians and nurses, and Washington State law recognizes this. No physician or other health care worker can be required to participate in not just an abortion but in any “specific service if they object to so doing for reason of conscience” (RCW 48.43.065 (2)(a) ). The misrepresentations or medical ignorance of objectors to conscience rights notwithstanding, emergency contraception medications clearly have abortifacient mechanisms that may even be the primary mechanisms of action, by making the endometrial lining non-receptive to implantation and thus causing fetal demise; this is noted in the FDA-approved drug statement for Plan B. Therefore, pharmacists are and ought to be protected by conscience provisions in Washington law regarding abortion. However, since Washington law protects all conscience, not just as it relates to abortion, disagreements regarding abortifacient mechanisms of contraceptives are moot; they are raised by objectors to conscience rights as a diversion from the real issue of the right to conscience.

Regarding the duty to refer when a pharmacist exercise conscience, it is the patient’s obligation in all cases to find appropriate medical services. The pharmacist is not an employee of the patient and is not obligated to arrange for the patient’s healthcare. If a patient goes to a physician’s office and is told that the physician is not taking new patients or does not provide a certain service, the physician is not given the obligation of tracking down another provider or arranging an alternative appointment; the duty remains with the patient to arrange his or her own health care. It is appropriate and consistent with the treatment of other health care professionals that pharmacists not be unfairly burdened by obligations not imposed upon their colleagues.

The Board received a letter dated August 4, 2005 from the Northwest Women’s Law Center (NWLC) and various abortion providers expressing opposition to the right of conscience of pharmacists. Without attempting a lengthy review of this letter, I believe a few comments are necessary to correct misunderstandings or misrepresentations made to the Board therein.

Opponents of conscience rights claim in the NWLC letter that refusing to fill a prescription represents an attempt by pharmacists to “force their personal values” or impose their own morals on the patient, but a moment’s reflection shows that this is not the case. If a passenger hails a taxi and tells the taxi driver to drive 20 miles an hour faster than the driver feels it is safe to do, we would not accuse the driver of imposing his morality on the rider if he refused. Similarly, if a patient approaches a pharmacist and asks for a prescription to be filled that the pharmacist considers morally objectionable, a pharmacist is not imposing his or her morals on the patient by refusing to participate.

Charges of sexual discrimination in exercising conscience are misdirected. Such charges would be valid if there were a gender-based refusal to provide pharmaceutical services, but in fact it is a medication-based refusal. Pharmacists who exercise conscience do not refuse to serve women in general, they only refuse to dispense particular medications in accord with the protections afforded them by RCW 9.02.150 and RCW 48.43.065.

Concerns regarding the ready and rapid availability of emergency contraceptive medications in locations rural or otherwise are unfounded, as these medications are available statewide from pharmacists, emergency rooms, physicians who choose to dispense them and from Planned Parenthood clinics, as well as through overnight mail.

While the letter writers correctly state that Washington women have a right to choose emergency contraceptive medications, they are in error when asserting that Washington law does not permit pharmacists to refuse to dispense contraception because of personal beliefs; Washington State law explicitly does protect this right in RCW 48.43.065 (2) (a).

The parties to the NWLC letter recognize that Washington State law does not support their claims, therefore they seek to force the Board to provide them a regulatory end run around the clear protections guaranteed to exercisers of conscience in Washington State. If Washington law did support their claims, they would have already sought and received broad injunctive relief in the courts. The Washington State Board of Pharmacy should not be pressured to develop policies in conflict with Washington State law, but rather should continue to ensure policies in accord with that law, as well as with the fundamental human right not to participate in actions which are held to be morally unacceptable. The protections afforded to pharmacists and other health care workers under Washington State law are laudable and we would wish these protections were similarly provided in all states.

The ultimate question regarding the right to conscience is whether pharmacists are simply drug dispensing clerks who must unquestioningly fill every prescription presented to them, or whether they have the autonomy and indeed the duty to behave in a manner reflecting their broad understanding of medicine, and respecting individual ethics. I contend that the entire history and tradition of pharmacy as a profession reject the former proposition and endorse the latter.

Thank you for your consideration and for your efforts to protect the profession of pharmacy.

Shane E. Macaulay, MD

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